L E T T E R

TO THE EDITOR

The Sonographic Patterns of

Xanthogranulomatous Pyelophlebitis
Yi-Hong Chou*, Chui-Mei Tiu

We enjoyed the review article by Drs. Kao and Wu
[1] in the June 2008 issue of Journal of Medical
Ultrasound, in which their experience in the evalu-
ation of renal infectious diseases using ultrasound
was presented. The authors also reviewed the per-
tinent literature. The review is very readable and
could be an important reference for urinary system
imaging experts. However, I would like to add cer-
tain points on the ultrasonography (US) patterns of
xanthogranulomatous pyelophlebitis (XGP), which
I believe are worthy of emphasis. XGP is a relatively
uncommon chronic inflammatory disease of the
kidney. This disease involves a chronic suppurative
granulomatous infection in which chronic obstruc-
tion may play an important role. US is frequently
requested to evaluate patients with clinical mani-
festations such as flank pain, fever, hematuria, flank
mass, and urinary frequency. As mentioned by
Drs. Kao and Wu, diffuse renal enlargement with a
central echogenic foci representing calculus is a
classic US presentation. However, there are still
a number of patients who show a different pattern
on US.
Since 1988, we have examined more than 50
patients with XGP in our ultrasound division. The
kidneys affected by XGP are usually diffusely en-
larged. This pattern accounts for about three-
quarter of cases. In a review of 27 patients with
XGP [2], we classified the US patterns of XGP into
four groups:
1. Diffuse hydronephrotic XGP, 44% of patients
(12/27): The diseased kidneys were enlarged
because of the presence of hydronephrosis. Com-
munications between the calyces and the pelvis
were noted with the presence of internal echoes,
representing debris or pus in the dilated collect-
ing system. This was frequently associated with
renal stones. The etiology of obstruction included
ureteral stone, renal stone combined with ure-
teral stone, and neogrowth from the bladder.
2. Diffuse parenchymal XGP, 33% of patients
(9/27): These kidneys showed enlargement but
no strong sonographic evidence of pyelectasia.
The parenchymal echo-pattern is diffusely dis-
torted and replaced by hypoechoic areas repre-
senting necrotic tissue or xanthogranulomatous
nodules. The dilated calyces presented as hypo-
echoic foci of variable sizes. The etiology of ob-
struction included staghorn stone (two cases),
staghorn stone and ureteropelvic junction stone
(two cases), nodular renal stone (two cases),
and ureteropelvic junction stone (one case).
3. Diffuse contracted XGP, 15% of patients (4/27):
Diffusely increased renal echogenicity was noted
in the contracted renal parenchyma. Loss of
corticomedullary junction was present.

Received: August 7, 2008 Accepted: August 25, 2008

Department of Radiology, Taipei Veterans General Hospital, and National Yang Ming University, School of
Medicine, Taipei, Taiwan.
*Address correspondence to: Dr. Yi-Hong Chou, Department of Radiology, Taipei Veterans General Hospital,
201, Section 2, Shih-Pai Road, Taipei 112, Taiwan. Email: yhchou@vghtpe.gov.tw

Elsevier & CTSUM. All rights reserved. J Med Ultrasound 2008 Vol 16 No 3 237
 Y.H. Chou, C.M. Tiu
4. Segmental or localized XGP, 7% of patients
(2/27): Focal mass with hypoechogenicity and
the presence of renal stones were found. Local-
ized perinephric fluid was present in 15% of all
cases (4/27). With the exception of segmental
XGP, the reniform shape is largely preserved in
kidneys affected by XGP.
Because diffusely contracted kidney (15%) and
segmental or localized XGP (7%) can be encoun-
tered, we would like to stress that these two pat-
terns should also be kept in mind. We expect that
238 J Med Ultrasound 2008 Vol 16 No 3
Dr. Kao and Dr. Wu will agree with us and we look
forward to their comments.
References
1. Kao HW, Wu CJ. Ultrasound of renal infectious dis-
ease. J Med Ultrasound 2008;16:11322.
2. Tiu CM, Chou YH, Chiou HJ, et al. Sonographic fea-
tures of xanthogranulomatous pyelonephritis. J Clin
Ultrasound 2001;29:27985.